In the event treatment is provided to a HealthChoice member for injuries sustained in an accident, and there is a third party at fault, the plan has subrogation rights. It is important for Network Providers to be aware that the Provider Contract requires providers to file claims with HealthChoice. In addition, the Provider Contract prohibits Network Providers from collecting from the member any amounts in excess of the allowable fee and/or which exceed the member’s deductible and coinsurance liability. The only exception would be for services not covered by the Plan or if annual or lifetime benefit limits have been reached.
More information regarding Subrogation can be found in Oklahoma Statutes, Title 74, Section 1306.1. Subrogation information is also available in the unofficial copy of the Administrative Rules 360:10-5-100 at www.ok.gov/sib/documents/Rules.pdf.